Kristen E. D'Anci, PhD; Stacey Uhl, MS; Gina Giradi, MS; Constance Martin, BA
Financial Support: By the U.S. Department of Veterans Affairs Veterans Health Administration.
Disclosures: Dr. D'Anci reports grants from the U.S. Department of Veterans Affairs during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0869.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Available at www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=104978. Statistical code: Not applicable. Data set: See the Supplement.
Corresponding Author: Kristen E. D'Anci, PhD, Senior Associate Director, Center for Clinical Evidence and Guidelines, ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA 19462-1298; e-mail, email@example.com.
Current Author Addresses: Dr. D'Anci, Ms. Uhl, Ms. Giradi, and Ms. Martin: Center for Clinical Evidence and Guidelines, ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA 19462-1298.
Author Contributions: Conception and design: K.E. D'Anci, S. Uhl.
Analysis and interpretation of the data: K.E. D'Anci, S. Uhl.
Drafting of the article: K.E. D'Anci, S. Uhl, G. Giradi, C. Martin.
Critical revision of the article for important intellectual content: K.E. D'Anci.
Final approval of the article: K.E. D'Anci, S. Uhl, G. Giradi, C. Martin.
Statistical expertise: K.E. D'Anci.
Collection and assembly of data: K.E. D'Anci, S. Uhl, G. Giradi, C. Martin.
Suicide is a growing public health problem, with the national rate in the United States increasing by 30% from 2000 to 2016.
To assess the benefits and harms of nonpharmacologic and pharmacologic interventions to prevent suicide and reduce suicide behaviors in at-risk adults.
MEDLINE, EMBASE, PsycINFO, and other databases from November 2011 through May 2018.
Systematic reviews (SRs) and randomized controlled trials (RCTs) that assessed nonpharmacologic or pharmacologic therapies for adults at risk for suicide.
One investigator abstracted data and assessed study quality, and a second investigator checked abstractions and assessments for accuracy.
Eight SRs and 15 RCTs were included. The evidence for psychological interventions suggests that cognitive behavioral therapy (CBT) reduces suicide attempts, suicidal ideation, and hopelessness compared with treatment as usual (TAU). Limited evidence suggests that dialectical behavior therapy (DBT) reduces suicidal ideation compared with wait-list control or crisis planning. The evidence for pharmacologic treatments suggests that ketamine reduces suicidal ideation with minimal adverse events compared with placebo or midazolam. Lithium reduces rates of suicide among patients with unipolar or bipolar mood disorders compared with placebo. However, no differences were observed between lithium and other medications in reducing suicide.
Qualitative synthesis of new evidence with existing meta-analyses, methodological shortcomings of studies, heterogeneity of nonpharmacologic interventions, and limited evidence for pharmacologic treatments and harms.
Both CBT and DBT showed modest benefit in reducing suicidal ideation compared with TAU or wait-list control, and CBT also reduced suicide attempts compared with TAU. Ketamine and lithium reduced the rate of suicide compared with placebo, but there was limited information on harms. Limited data are available to support the efficacy of other nonpharmacologic or pharmacologic interventions.
U.S. Department of Veterans Affairs Veterans Health Administration. (PROSPERO: CRD42018104978)
Appendix Table 1. Literature Search Strategy: EMBASE Syntax
Appendix Table 2. Literature Search Strategy: PsycINFO Syntax
Appendix Table 3. Literature Search Strategy: PILOTS Database Syntax
Appendix Table 4. Study Quality Checklist for RCTs, Based on USPSTF Criteria
Evidence search and selection.
KQ = key question; SR = systematic review.
* Not relevant to topic, not published in English, or published before inclusion date.
† Not clinical trial or SR, did not address KQ, did not report on outcome of interest, or outside publication cutoff dates.
Table 1. Nonpharmacologic Interventions for Suicide Prevention*
Table 2. Evidence for Other Nonpharmacologic Interventions*
Table 3. Pharmacologic Interventions for Suicide Prevention*
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D'Anci KE, Uhl S, Giradi G, et al. Treatments for the Prevention and Management of Suicide: A Systematic Review. Ann Intern Med. [Epub ahead of print 27 August 2019]171:334–342. doi: 10.7326/M19-0869
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Published: Ann Intern Med. 2019;171(5):334-342.
Published at www.annals.org on 27 August 2019
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